April 2020 HSC Section 4 - Plastic and Reconstructive Problems

Plastic and Reconstructive Surgery • July 2019

To repair isolated intranasal lining defects, Walton et al. prefabricated a composite flap on the forearm, fashioned with forehead skin, skin grafts, and rib grafts. 9 We believe our circumferen- tial single radial forearm paddle approach is less complex and more adaptable. We are pleased with the aesthetic and func- tional results of the single-paddle microvascular folded radial forearm flap (two folds or one fold) for total/subtotal nasal defects and a single circu- lar flap for lining defects only 15 (Figs. 7 through 9). We will publish technical details and outcomes of the second-stage forehead flap, intermediate stage, and late revision stages in the future. CONCLUSIONS The first stage of a total/subtotal nasal recon- struction, using an infolded microvascular radial forearm flap with a primary dorsal cartilage graft, is the foundation on which subsequent proce- dures are based. These staged procedures require forehead flap resurfacing, cartilage grafts, and sculpting procedures. Initially, the infolded flap nourishes a primary dorsal cartilage graft; later, in the second stage, it provides additional skin to reshape the nostrils and columella. When only lining is missing in primary intranasal defects, a circumferential flap restores missing vault and floor lining and allows placement of a dorsal and columellar cartilage support. Although the fore- arm flap will eventually provide lining only, the initial steps of the microvascular flap contouring for central support and nostril shaping are the foundation for a successful staged microvascular nasal repair. Arthur H. Salibian, M.D. 1310 Stewart Drive, Suite 211 Orange, Calif. 92868 arthursalibian@gmail.com

PATIENT CONSENT Patients provided written consent for the use of their images.

REFERENCES 1. Song R, Gao Y, Song Y, Yu Y, Song Y. The forearm flap. Clin Plast Surg . 1982;9:21–26. 2. McCraw JB, Furlow LT Jr. The dorsalis pedis arterialized flap: A clinical study. Plast Reconstr Surg . 1975;55:177–185. 3. Swartz WM. Microvascular approaches to nasal reconstruc- tion. Microsurgery 1988;9:150–153. 4. Shaw WW. Microvascular reconstruction of the nose. Clin Plast Surg . 1981;8:471–480. 5. Pribaz JJ, Weiss DD, Mulliken JB, Eriksson E. Prelaminated free flap reconstruction of complex central facial defects. Plast Reconstr Surg . 1999;104:357–365; discussion 366–367. 6. Taghinia AH, Pribaz JJ. Complex nasal reconstruction. Plast Reconstr Surg . 2008;121:15e–27e. 7. Burget GC, Walton RL. Optimal use of microvascular free flaps, cartilage grafts, and a paramedian forehead flap for aesthetic reconstruction of the nose and adjacent facial units. Plast Reconstr Surg . 2007;120:1171–1207; discussion 1208–1216. 8. Seth R, Revenaugh PC, Scharpf J, Shipchandler TZ, Fritz MA. Free anterolateral thigh fascia lata flap for complex nasal lining defects. JAMA Facial Plast Surg . 2013;15:21–28. 9. Walton RL, Burget GC, Beahm EK. Microsurgical reconstruction of the nasal lining. Plast Reconstr Surg . 2005;115:1813–1829. 10. Menick FJ, Salibian A. Microvascular repair of heminasal, subtotal, and total nasal defects with a folded radial forearm flap and a full-thickness forehead flap. Plast Reconstr Surg . 2011;127:637–651. 11. Gillies HD, Millard DR. The Principles and Art of Plastic Surgery . Boston: Little, Brown; 1957. 12. Converse JM. Reconstruction of the nose by the scalping flap technique. Surg Clin North Am . 1959;39:335–365. 13. Menick FJ, Salibian A. Primary intranasal lining injury cause, deformities, and treatment plan. Plast Reconstr Surg . 2014;134:1045–1056. 14. Hsiao YC, Huang JJ, Zelken JA, et al. The folded ulnar forearm flap for nasal reconstruction. Plast Reconstr Surg . 2016;137:630–635. 15. Menick FJ. Aesthetic Nasal Reconstruction: Principles and Practice . Publisher: www.aestheticnasalreconstruction.com; 2017.

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